Patients undergoing anatomic total shoulder arthroplasty achieve clinically significant outcomes faster than those undergoing reverse shoulder arthroplasty.

BACKGROUND: Clinically significant outcome (CSO) benchmarks have been previously established for outcome assessment after total shoulder arthroplasty. However, the time required to achieve CSO improvement is not well understood. The purpose of this study was to (1) determine the time-dependent achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) in patients undergoing either anatomic total shoulder (TSA) or reverse total shoulder arthroplasty (RTSA) and compare the results of the 2 populations and (2) identify variables associated with earlier or delayed achievement of each CSO. METHODS: A prospectively maintained institutional registry was retrospectively queried for all patients receiving a primary TSA or RTSA between September 2, 2016-October 31, 2017. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was administered to all patients preoperatively and at standardized postoperative time periods: 5-7 months (6-month time point), 11-13 months (1-year time point), and 23-25 months (2-year time point). Cumulative percentages of CSO achievement were calculated using Kaplan-Meier survival curve analysis with interval censoring. A Weibull parametric survival regression analysis was used to investigate the influence of demographic and clinical variables on delayed or earlier CSO achievement. RESULTS: A total of 153 patients (157 shoulders) undergoing TSA (n = 76) and RTSA (n = 81) were included in the study population. The RTSA cohort was older (70.2 ± 7.5 vs. 61.0 ± 8.4, P < .001), had a lower BMI (28.8 ± 5.9 vs. 31.5 ± 6.5, P = .006), and a greater proportion of females (53.1% vs. 32.9%, P = .017) relative to TSA. For SCB, there was a significant difference in the cumulative percentage of TSA and RTSA patients reaching this threshold at both the 6-month (77.3% vs. 59.0%, P = .024) and 2-year (92.0% vs. 79.5%, P = .048) time periods, with similar findings demonstrated for PASS. There was a significant difference in the average time required to achieve the PASS (TSA: 6.1 months vs. rTSA: 11.6 months, P = .009), but not the MCID (P = .407) or SCB (P = .153). Factors significantly associated with earlier achievement of more than 1 of the CSO benchmarks were regular preoperative physical exercise and diagnosis of rotator cuff tear without osteoarthritis. CONCLUSION: Patients undergoing RTSA had lower rates of achieving SCB and PASS at both 6 months and 2 years compared to patients undergoing TSA. Patients undergoing RTSA on average required nearly double the time to achieve PASS compared with those undergoing TSA. In both groups, clinically significant improvement continued for the entire 2-year duration of study follow-up.

Establishing clinically significant outcome thresholds for the Single Assessment Numeric Evaluation 2 years following total shoulder arthroplasty.

BACKGROUND: Single Assessment Numerical Evaluation (SANE) is a simple, time-efficient patient-reported outcome measure (PROM) used to assess postoperative shoulder function. Clinically significant outcome values and ability to correlate with longer legacy PROM scores at 2 years following shoulder arthroplasty are unknown. METHODS: A retrospective analysis was performed using SANE, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores that were collected at a minimum 2-year follow-up. A total of 153 patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were included. A distribution-based method was used to determine the minimal clinically important difference (MCID). An anchor-based method was used to determine substantial clinical benefit (SCB). The following anchor question was collected alongside the PROMs and graded on a 15-point Likert-type scale to establish the SCB: "Since your surgery, has there been any change in the pain in your shoulder?" Linear regression was used to assess correlations between PROMs. RESULTS: SANE showed moderate correlation with ASES (R2 = 0.493) and Constant (R2 = 0.586) scores (P < .001). The MCID value was 14.9, and the SCB absolute value was 80.4 (area under the curve = 0.663) for SANE. Multivariate logistic regression demonstrated that patients undergoing RTSA were less likely to achieve SCB on all 3 outcome measures (P < .02). CONCLUSIONS: This study establishes concurrent construct validity for SANE and suggests that it is a valid metric to assess the MCID and SCB at 2 years following anatomic TSA and RTSA. SANE demonstrated moderate correlations with ASES and Constant scores. Patients undergoing RTSA demonstrated a lower propensity to achieve SCB at 2 years postoperatively compared with anatomic TSA.

Perioperative Opioid Use Predicts Postoperative Opioid Use and Inferior Outcomes After Shoulder Arthroscopy.

PURPOSE: The purpose of this study is to define the impact of preoperative opioid use on postoperative opioid use, patient-reported outcomes, and revision rates in a cohort of patients receiving arthroscopic shoulder surgery. METHODS: Patients who underwent shoulder arthroscopy were identified from an institutional database. Inclusion criteria were completion of preoperative and postoperative patient-reported outcome measures (PROMs) at 1-year follow-up and completion of a questionnaire on use of opioids and number of pills per day. Outcomes assessed included postoperative PROM scores, postoperative opioid use, persistent pain, and achievement of the patient acceptable symptomatic state. A matched cohort analysis was performed to evaluate the impact of opioid use on achievement of postoperative outcomes, whereas a multivariate regression was performed to determine additional risk factors. Receiver operating characteristic curves were used to establish threshold values in oral morphine equivalents (OMEs) that predicted each outcome. RESULTS: A total of 184 (16.3%) patients were included in the opioid use (OU) group and 1,058 in the no opioid use (NOU) group. The OU and NOU groups showed statistically significant differences in both preoperative and postoperative scores across all PROMs (P < .001). Multivariate logistic regression identified preoperative opioid use as a significant predictor of reduced achievement of the patient acceptable symptomatic state (odds ratio [OR], 0.69, 95% confidence interval [CI], 0.29-0.83, P = .008), increased likelihood of endorsing persistent pain (OR, 1.73, 95% CI, 1.17-2.56, P = .006), and increased opioid use at 1 year (OR, 21.3, 95% CI, 12.2-37.2, P < .001). Consuming a high dosage during the perioperative period increased risk of revision surgery (OR, 8.59, 95% CI, 2.12-34.78, P < .003). Results were confirmed by matched cohort analysis. Receiver operating characteristic analysis found that total OME >1430 mg/d in the perioperative period (area under the curve, 0.76) and perioperative daily OME >32.5 predicted postoperative opioid consumption (area under the curve, 0.79). CONCLUSIONS: Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcomes after arthroscopic shoulder surgery. However, preoperative opioid use negatively impacts patients' level of satisfaction and is a significant predictor of pain and continued opioid usage. LEVEL OF EVIDENCE: Level III, retrospective cohort study.